Elizabeth Wettlaufer is one of Canada’s worst serial killers, and had she not made comments about her acts to a psychiatric nurse, she very well could have continued to kill.

Last week, the public inquiry into how Wettlaufer got away with her crimes went on hiatus until mid-July. But the testimony so far paints a damning picture of the state of long-term care in Ontario’s old age and assisted living residences.

The litany of failures: from cost cutting measures to limited supervision, from inadequate discipline, to a nursing shortage, created the ideal conditions for Wettlaufer to kill.

Wettlaufer killed seven people at Caressant Care nursing home in Woodstock, Ontario, and one person at Meadow Park nursing home in London. She poisoned six others, including in a patient’s home while she worked for St. Elizabeth Home Health Care in Oxford County. The murders happened between 2007 and 2016.

My grandmother spent her final months at Meadow Park last year.

Management knew Elizabeth Wettlaufer made 'very dangerous' errors with medication

CBC London reporter Kate Dubinski has been chronicling the inquiry and the various regulatory failures and inept practices that enabled Wettlaufer. Her Twitter feed is filled with problems at long-term care facilities and temporary hiring agencies in and around London, where Wettlaufer worked.

Wettlaufer was found to be a deficient nurse in so many ways: at St. Elizabeth Home Health Care in 2016, she was certified to be able to insert a PICC line, used to administer IV drugs for an indefinite period of time, despite the fact that she never could demonstrate to her supervisor that she could do this without botching the procedure.

At Telfer Place where she worked as a nurse placed by a temporary agency at the end of 2015, she didn’t complete paperwork. She left the medication room unlocked, a practice that violated protocol and could pose a risk to residents. She didn’t relay important health information to doctors and other nurses. She didn’t properly clean residents.

Wettlaufer worked at Caressant Care in Woodstock, Ontario until 2014. There, she murdered seven people. Caressant Care filed a termination report with Ontario’s nursing regulator, the Ontario College of Nurses, that was so long that they couldn’t fit the infractions onto the form, the inquiry heard. She was crass, inappropriate and even made sexual advances at some student nurses.

The vulnerability of Elizabeth Wettlaufer’s victims made them easy prey, writes @NoLore. Worse, even when there were red flags, professionals looked the other way.

At the inquiry, an email from 2014 showed that senior management found the errors that Wettlaufer was making with medication to be “very dangerous.”

Wanda Sanginesi, the vice-president of human resources at Caressant Care, told the inquiry that Wettlaufer would have been fired sooner, if hadn’t been for the union. When cross-examined by Kate Hughes, lawyer for the Ontario Nurses Association, about why certain records about Wettlaufer’s performance had never been shared with the union, Sanginesi said, “I think she fooled everybody," a reply that doesn’t line up with the apparently widespread feeling that she was dangerously incompetent. ​

But Caressant Care seemed to be more worried about the cost of arbitration than the importance of firing Wettlaufer properly. CBC reported, “Caressant Care wanted to settle the matter instead of taking it to arbitration, which would cost a lot of money,” a big problem when money is tight and your institution is for-profit.

Caressant Care donated thousands to provincial Liberals and Tories

From 2014 to 2016, Caressant Care donated $8224 to the Ontario Liberal Party and $6007.47 to the Ontario Progressive Conservatives.

Caressant Care negotiated a settlement with Wettlaufer and her union that included a $2000 payout, and a letter of reference that didn’t refer to any wrongdoing on Wettlaufer’s part. All future references were supposed to be handled by Sanginesi directly. But Caressant Care gave Wettlaufer good references twice that didn’t respect the agreed-upon protocol.

Not that it necessarily mattered. When St. Elizabeth hired Wettlaufer, they didn’t bother calling Wettlaufer’s references.

Advances in healthcare and an aging population have made long-term care increasingly more difficult, and understaffing is a big part of the problem. The executive director of Telfer Place, Dian Shannon, in a written statement, told the inquiry “We’re underfunded. There should never be a nursing home where you just have two people on at night, but [fewer than 2 nurses on duty] happens all the time.” In one case, Shannon, who is not a nurse, filled in for a nurse shortage and administered medication herself.

Wettlaufer was often working alone at night as the only nurse on duty.

A funding crisis drives insufficient supervision, ineffective discipline and a desire to avoid extra costs that come with doing the job properly. While it’s easy to blame the union on Wettlaufer sins, cutting corners in long-term care homes is a far greater problem. Especially since it’s so widespread.

In October 2017, then-health minister Eric Hoskins ordered that three Ontario nursing homes stop admitting new residents because of their substandard care. Caressant Care’s Fergus facility was one of the three, where inspectors found 14 violations in how they cared for residents. In 2008, 53 per cent of Ontario’s nursing home beds were at private, for-profit facilities, double what it was a decade earlier. Research shows that residents in municipally-owned facilities receive an average of 20 minutes more direct care than residents in for-profit chain facilities.

From 2012 to 2014, Dubinsky reported on Twitter that Meadow Park, Wettlaufer’s last nursing home employer, was feeding residents on just $7.80 per day. It’s increased to $9.53 per day, which is, alarmingly, above the provincial average of $8.33 per day.

The vulnerability of Wettlaufer’s victims made them easy prey, and worse, even when there were red flags, professionals looked the other way. Caressant Care nurse Laura Long felt something was off about the death of Maureen Pickering. When she raised her concerns with the doctor, he said: “No death in a nursing home is unexpected.” If residents are expected to simply be living out the clock until death, how can that life ever be dignified?

Elderly Ontarians deserve care and respect. The only good that could come out of the horror of Wettlaufer’s crimes would be for Ontarians to pay close attention to this inquiry and demand that their government acts on its recommendations, anticipated in 2019.

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Back in the '80's and '90's I sat on the Board of a non-for-profit LTC facility. During that time the Board undertook some crash course education in the workings of care facilities. Previously I had worked on Bob Rae's community consultation process trying to reform the entire long term, chronic and home care sectors of the Ontario health care system. That too, was a steep learning process trying to understand the disparate operations of the various service providers as well as the existing ministry overseers and the regional agencies trying to coordinate provider services and client access. We met at least monthly for more than a year and achieved almost nothing in the way of rationalization or improved service levels or client access. It was obvious that most of the sectors involved - most especially the service providers, both for profit and not-for-profit, were intransigent on the issue of rationalization and utterly opposed to any suggestion of amalgamation. It was one of the most frusrating experiences of my life. All of that effort was swept into the shredder when Mike Harris became premier and began a wholesale top down reform of the entire sector - largely ignoring the few recommendations the task forces managed to produce.

The Harris solution was to open the LTC market to the U.S. style (and largely American owned) corporations who had lobbied fiercely for Ministry approval and funding.

Typcally, corporate investment flooded the market with much needed new LTC facilities - but these were lumbered with the same funding formulas and operational requirements of the not-for-profit sector and overseen by the same bureaucrats from the newly established LTC addition to the Ministry of Health.

Government funding formulas were never quite enough to provide the level of care the regulations required and the nfp's continued to fund raise in their communities to make up the shortfalls. The corporations' response was to "achieve greater efficiencies" by consistently shortchanging the services provided. This outcome was inevitable and the results are obvious.

The Wettlaufer case is merely the rat's nest that has been uncovered. The hourly degradations LTC residents endure continues, unabated.